New Client/Patient Survey Milan Area Animal Hospital (MAAH) is currently booking 3 - 4 weeks out for appointments and we are no longer accepting new clients on an emergent basis. Here at MAAH we want to partner with you for your pet(s) healthcare needs. Due to a massive increase in client needs recently, we are no longer able to accept new clients without pre-screening to ensure that we are establishing a good doctor/client relationship. A good veterinary doctor/client relationship is based on honesty, respect and communication. Please fill this form out and return with all previous veterinary history. CLIENT INFORMATION: Name* First Last Phone** CELL HOME Alt Phone:Alternate Contact Name:Relationship:Phone:Is pet residing with Primary client?*YesNoIf yes, for how long?Permission for alternate to give consent for procedures and/or medications?*YesNoPATIENT INFORMATION: Pet Name*NicknameSpecies:* Canine Feline Avian Rodent Reptile BreedAge*Sex*Spayed/Neutered*YesNoAt what age was pet spayed/neutered?*What is your pets normal diet?Is this pet kept current on: Vaccinations (Distemper, Rabies, etc.)*YesNoIf not current, when was the last time given?Yearly Blood work (Chemistries & CBC)*YesNoIf not current, when was the last time done?Heartworm Testing*YesNoIf not current, when was the last time done?Testing for Tick-Borne Diseases (inc Lyme)YesNoIf not current, when was the last time done?Fecal tests*YesNoHow often is testing done?Every 6 MonthsYearlyIf not current, when was the last time done?Is your pet on heart-worm prevention?*YesNoIf yes, which oneDo you keep your pet on this prevention year round?YesNoIs your pet on flea & tick prevention?*YesNoIf yes, which oneDo you keep your pet on this prevention year roundYesNoIs your pet on any other medications? (Please list medication, frequency, and condition being treated) Does your pet have a Chronic medical condition?YesNoIf yes, describe belowDoes your pet reside*InsideOutdoorsBothDoes your pet have any behavioral problems that you are concerned with?*YesNoIf yes, explain I hereby agree that the information provided is true and precise, to the best of my knowledge. Signature* Reset signature Signature locked. Reset to sign again Date* Date Format: MM slash DD slash YYYY Medical Records Drop files here or Did you have your records sent to our office at 734-439-0556? If not, please upload records at this time.